Marianna Crane

Cardiac Advances Versus Patient Benefit: A Moral Dilemma

My story, Closing the Door, recently published in Stories That Need to be Told: A Tulip Tree Anthology, tells of the emergence some fifty years ago of cardiac catheterization, artificial heart valves and cardiopulmonary resuscitation and how I, as a young nurse, had to make sense of the advancement of technology versus patient benefit.

This story is especially significant to me because just six months ago my husband had open-heart surgery replacing two valves with biological valves. I witnessed, first hand, the tremendous advances in cardiac surgery and treatment.

CLOSING THE DOOR

I gagged on the alcohol fumes as I carefully measured out sixty milliliters of Black and White Scotch into a medicine glass. Balancing the small plastic tray with a pack of Lucky Strikes and the Scotch on one hand, I locked the door to the tiny medication room with the other. Then I went in search of Charlie Hobbs.

A plume of tobacco smoke drifted from the patients’ lounge. A ripped vinyl sofa and two orange bucket-like chairs lined the walls. The sole occupant was a middle-aged man hunched over a jigsaw puzzle on the card table. Charlie Hobbs had been admitted to the research unit on the third floor of the city hospital with just the clothes on his back. Every day he wore the hospital issued striped robe and pajamas. One of other staff nurses had donated slippers.

I gazed down at the top of Charlie’s wild red hair. He shuffled jigsaw pieces by day and watched television by night, all a maneuver, I thought, to keep human interaction at bay. No one ever visited him. Did he even have a home to go back to?

“I got to get me another puzzle,” he said without looking up. “This here one is almost done.”

At twenty-three, and a nurse for just two years, I vacillated between professionalism and irreverence. At times, I imagined myself the airline stewardess I had always wanted to be. Coffee, tea, or me? This day I was a Playboy Bunny as I bent at the knees, stretching to place the drink in front of Charlie, while his blue eyes riveted on my imagined cleavage. But Charlie’s eyes fixed solely on the amber liquid. Not once in the past four weeks had he acknowledged me, the young nurse in a starched white uniform with thick support hose, and practical shoes. An unlikely dispenser of booze and butts.

Charlie snuffed out the remnant of his cigarette into an overflowing ashtray and reached for the drink.

Harold Clark’s research money supported Charlie’s hospital stay. Dr. Clark needed recruits who would agree to have a cardiac catheterization in order to see the effects, if any, that alcohol had on their hearts. Cardiac catheterization was the latest tool of the sixties to measure heart function. This new procedure carried a high risk of injury, and even death.

Dr. Clark had scoured the downtown bars searching for men who drank excessively. On a warm autumn night he had gotten lucky. Charlie seized the carrot: a roof over his head, three squares a day plus free liquor and cigarettes. He agreed to live on the research unit for a month, and then undergo a cardiac catheterization.

I carried the empty medicine glass and the tray back to the nursing station. How could Charlie drink alcohol at nine in the morning? Or all day long, for that matter? What would make a man so desperate that he would consent to undergo a procedure that might kill him?

Even though I didn’t particularly like Charlie, there were times when I placed the Scotch in front of him that I wanted to nudge him, and jerk my head towards the exit sign at the end of the hallway. Get out, Charlie. The catheterization isn’t worth all the free alcohol and cigarettes. But I didn’t have the audacity to undermine Dr. Clark’s research, no matter how conflicted I felt.

In the small sink in the medicine room, I rinsed out the glass and turned it upside down to dry on a paper towel that rested on the narrow windowsill. Still thinking of Charlie Hobbs, I started down the hall to check on my other patients.

Nellie Mineo waved to me from the doorway of her husband’s room. She looked like the Italian housewife that she was: salt and pepper hair piled in a bun on the top of her head. A well-worn cardigan sweater covered her simple cotton dress. When I walked toward her, she grabbed my hand. Behind her I could just make out her husband’s outline under the starched white sheets.

The Mineos had known the chances weren’t in their favor when they first met with Dr. Clark to discuss replacing Joe’s diseased heart valve with an artificial one. He was so short of breath that he could hardly talk, much less continue working in the family grocery store.

In the operating room, Dr. Clark had removed the incompetent valve, and slipped the artificial one, a silastic ball encased in metal cage, into the excavated space. The ball-valve clicked audibly. Not a pleasant side effect.

After my regular tour of duty, I rode the elevator to the fifteenth floor, the surgical unit, and worked overtime as Joe’s private nurse. He reminded me of my Uncle Tony with olive skin, dark eyes, and soft smile. At first things looked great, but soon Joe developed a cough and a fever. His legs swelled. He had difficulty breathing. Diuretics worked for a while. Antibiotics failed to prevent an infection. His once muscular body had shriveled into sagging skin covering a bony frame. Although the valve was being rejected, it continued to click on.

“Stop and see me before you go off duty,” Nellie repeated. I nodded. Only then did she loosen her grip on my hand.

At the end of the day, as I flung my coat over my arm, I heard a racket from the patients’ lounge. Charlie stomped past me, head down, and fists clenched. “I’m outta here.”

“What happened?” I asked the nurse who jogged after Charlie.

“Charlie kicked over the card table. For no reason I could see.” She shrugged her shoulders, and continued on.

Nellie watched the commotion from the other side of the hall. The Mineo’s large, gregarious family resembled my own extended Italian family. Visitors came and went at all hours, but that day only Nellie stood guard. When I approached, she pulled me into her husband’s room, grabbed my coat and purse, and clutched them against her body. From behind her I could hear Joe’s wet bubbly breaths, which barely muffled the click of the valve. Even in my short stint as a nurse I recognized the rancid smell of impending death. I wanted to escape the hopelessness of Joe’s futile struggle, but Nellie moved her face closer to mine.

“He’s dying,” she whispered.

She swallowed hard as if to stop herself from crying. “I don’t want him resuscitated. Please stay with us. Don’t let them resuscitate him.”

Nellie had witnessed plenty of resuscitation attempts as she lingered outside her husband’s hospital room day after day. Cardiopulmonary resuscitation was so new that all patients were candidates. At the first moment a patient stopped breathing, we leapt into action. We flung him to the floor and straddled him. We thumped the sternum with the side of our fist, then breathed frantically into his mouth. Pumped on his chest. We worked until we were exhausted. In most cases the patient died anyway with fractured ribs, and a lacerated liver.

Nellie kept her gaze on me; her dark eyes pleading. What would I want for Uncle Tony? A quiet death, or zealots in white coats beating on his chest? What should I do?

Charlie’s voice boomed from down the hall spewing curses. Perfect timing. Charlie would leave the hospital AMA—against medical advice—right before his scheduled catheterization. He wasn’t as clueless as I had thought.

Hopefully, Charlie would distract the staff long enough for Joe to die. My heartbeats kicked up a notch. How could I ignore Nelly’s plea? I reached over and slowly shut the door.

Nellie’s hold on my coat and purse relaxed, and they slid to the floor. Wordlessly, she settled in the chair next to Joe’s bed, lifted his limp hand onto her lap. I commandeered the chair by the door: the sentry blocking the enemy from entering.

I had seen dead people before but never lingered for that final breath. The valve and the minutes clicked on. The lapses between Joe’s gasps for air stretched farther apart. Just when I thought he had quit breathing, he gulped for air. I silently cheered him on. Die Joe. Come on, get it over with.

I sat knotted tight. How would I explain the closed door to a co-worker who decided to check on Joe? Or the fact I was still there after my shift had ended?

Finally, Joe’s noisy breathing ceased. Then the mechanical valve stopped clicking. The silence sounded thunderous as I grappled with the fact Joe had actually died. I walked to the bed to see his torturous face frozen, his dark hair matted with sweat, his mouth agape. His open eyes stared at nothing. I placed my hand over Joe’s clammy hospital gown. No movement in his chest. No heart thumping against my palm. As I smoothed down his lids, Nellie gripped her husband’s hand to her breast and sobbed softly.

While I felt relief that Joe had died with his wife by his side, each footstep by the door made my heart flip.

“I really need to leave, Nellie.”

Tears trickled down her cheeks. She placed Joe’s hand over his chest before she rose from the chair to embrace me.

“Thank you,” she said, her voice cracking. She cried on my shoulder as my own tears fell. Then she pulled away, and sat back down next to Joe, taking his hand again.

Grabbing my coat and purse from the floor, I wiped the moisture off my face with the coat sleeve. I cracked open the door, and glanced up and down the empty hallway. I forced myself to walk leisurely toward the exit.

Nellie waited for the evening nurse to discover Joe dead in the bed.

The floor was unusually quiet. The medication door stood ajar in the nursing station. I had no intention of poking my head inside, and saying so long to the evening nurse. Just a few more steps and I would be in the clear.

I turned the corner of the white tiled hallway, my thoughts back in the room with Nellie and Joe. My body jerked as Charlie Hobbs blocked my way.

“Hi,” he said as if we were old friends. “I’m leaving.”

He sported a bright green jacket that covered the rumpled clothes he had worn when first admitted. “Borrowed this from the guy in the next room,” he said, noticing my eyes on the jacket. “I’ll return it.” I nodded even though I knew the coat would never make it back to its owner.

“I ain’t got no money on me. Can ya spare a buck? I’ll pay ya back.” He shifted his feet nervously waiting for my answer. For a fleeting moment, I thought to try to persuade him to stay. But that would have been hypocritical. I reached into my purse knowing he would head for the nearest tavern, and never give a second thought to repaying me.

“Thanks,” Charlie mumbled, shoving the dollar bill into the pocket of the purloined jacket. He turned abruptly, and disappeared though the doorway under the exit sign.

While I jogged down the three flights of stairs following behind Charlie’s footfalls, I attempted to justify my behavior. Frightening to me was how quickly I intervened for my patients without foresight into the repercussions.

However, I felt positive that Charlie had planned all along to leave the hospital before the catheterization. Not giving him the dollar wouldn’t have made a difference. And who would question that my closing the door to Joe’s room to allow him to die naturally had violated any ethical rule? Even if I didn’t intervene, the chances that anyone would get past Nellie Mineo to resuscitate Joe seemed unlikely.

How could I have realized that over the years I would continue to struggle with knowing when to step back, and when to dig deeper into my patients’ psyche. How to be empathic and not sympathetic? How to balance cool detachment with overbearing involvement? It was just the beginning. There would be many choices throughout my long nursing career that would test my allegiance, and strain my conscience.

Before I reached the last flight of stairs, Charlie had flung open the door to the street, and let it crash behind him.

Dear Marianna, Oh my goodness, this is by far my favorite post! You totally painted a picture of knowledge, caring and advocating for your patients. I could actually visualize you as you went through your day. The hospice philosophy wasn’t even spoken about in those days, but you performed as a caring hospice nurse would. You gave your patients a true gift . Times and research have certainly changed but the art of nursing goes on. I am happy with the advances in cardiac care and I’m sure that it’s very personal for you. This was truly a beautiful poignant piece!

Joan, I know that you have been part of the hospice movement for many years so I especially cherish your comments. And yes, the art of nursing continues in spite of all the changes and advances in health care.